Effect of alcohol in traumatic brain injury: is it really protective?

Approaches and reporting of alcohol and other drug testing for injured patients in hospital-based studies: A systematic review

ISSUE

Hospital alcohol and/or other drug (AOD) testing is important for identifying AOD-related injuries; however, testing methods vary. This systematic review aimed to examine biological AOD testing methods from hospital-based studies of injured patients and quantify what proportion reported key information on those testing methods.

APPROACH

Observational studies published in English from 2010 onwards involving biological AOD testing for injured patients presenting to hospital were included. Studies examining single injury causes were excluded. Extracted data included concentration thresholds for AOD detection (e.g., lower limits of detection, author-defined cut-offs), test type (e.g., immunoassay, breathalyser) and approach (e.g., routine, clinical discretion), timing of testing, sample type and the proportion of injured cases tested for AODs.

KEY FINDINGS

Of 83 included studies, 76 measured alcohol and 37 other drugs. Forty-nine studies defined blood alcohol concentration thresholds (ranging from 0 to 0.1 g/100 mL). Seven studies defined concentration thresholds for other drugs. Testing approach was reported in 39/76 alcohol and 18/37 other drug studies. Sample type was commonly reported (alcohol: n = 69/76; other drugs: n = 28/37); alcohol was typically measured using blood (n = 60) and other drugs using urine (n = 20). Studies that reported the proportion of cases tested (alcohol: n = 53/76; other drugs: n = 28/37), reported that between 0% and 89% of cases were not tested for alcohol and 0% and 91% for other drugs. Timing of testing was often unreported (alcohol: n = 61; other drugs: n = 30).

IMPLICATIONS AND CONCLUSION

Variation in AOD testing methods alongside incomplete reporting of those methods limits data comparability and interpretation. Standardised reporting of testing methods will assist AOD-related injury surveillance and prevention.

Prevalence of alcohol and other drug use in patients presenting to hospital for fall-related injuries: a systematic review

BACKGROUND

Alcohol and other drug (AOD) use is a key preventable risk factor for serious injuries. Prevention strategies to date have largely focused on transport injuries, despite AOD use being a significant risk factor for other injury causes, including falls. This systematic review aimed to report the prevalence of AOD use in patients presenting to hospital for fall-related injuries.

METHODS

This systematic review includes studies published in English after the year 2010 that objectively measured the prevalence of AOD use in patients presenting to hospital for a fall-related injury. Screening, data extraction and risk of bias assessments were completed by two independent reviewers. Data were presented using narrative synthesis and, where appropriate, meta-analyses.

RESULTS

A total of 12 707 records were screened. Full texts were retrieved for 2042 records, of which 29 were included. Four studies reported the combined prevalence of any alcohol and/or drug use, generating a pooled prevalence estimate of 37% (95% CI 25% to 49%). Twenty-two records reported on the prevalence of acute alcohol use alone and nine reported specifically on the prevalence of drugs other than alcohol, with prevalence ranging from 2% to 57% and 7% to 46%, respectively. The variation in prevalence estimates likely resulted from differences in toxicology testing methods across studies.

CONCLUSIONS

AOD exposure was common in hospitalised fall-related injuries. However, research addressing prevalence across different types of falls and the use of drugs other than alcohol was limited. Future research should address these areas to improve our understanding of which populations should be targeted in AOD and injury prevention strategies .

PROSPERO REGISTRATION NUMBER

CRD42020188746.

Vices-paradox in trauma: Positive alcohol and drug screens associated with decreased mortality

BACKGROUND

Improved survival in trauma patients with acute alcohol intoxication has been previously reported. The effect of illegal and controlled substances on mortality is less clear. We hypothesized that alcohol, illegal and controlled substances are each independently associated with lower odds of mortality in adult trauma patients.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for patients screening positive for alcohol, illegal or controlled substances on admission. A multivariate logistic regression analysis was used to determine odds of mortality. A similar analysis was used after stratification by injury severity scale (ISS).

RESULTS

From 1,299,705 adult patients, 660,135 were screened for substance use. Of these patients, 497,872 were male, 227,995 (34.5 %) screened positive for alcohol, 155,437 (23.5 %) for illegal substances and 90,259 (13.7 %) for controlled substances. Mortality rate was 6.2 % with alcohol, 5.1 % with illegal substances, and 5.7 % with controlled substances compared to 8.0 % with no substance use (p < 0.001). After controlling for covariates, all groups had lower odds of mortality: alcohol (OR = 0.88, CI = 0.84-0.92, p < 0.001), illegal substances (OR = 0.83, CI = 0.77-0.90, p < 0.001), controlled substances (OR = 0.72, CI = 0.67-0.79, p < 0.001). When stratified by ISS, alcohol and illegal substances continued to be associated with decreased mortality until ISS 50. Controlled substances were associated with decreased mortality when ISS > 16.

CONCLUSION

Patients positive for alcohol, illegal or controlled substances have 12 %, 17 %, and 28 % decreased odds of mortality, respectively. This paradoxical association should be confirmed with future clinical studies and merits basic science research to identify biochemical or physiological components conferring a protective effect on survival in trauma patients.

Alcohol and trauma: the influence of blood alcohol levels on the severity of injuries and outcome of trauma patients - a retrospective analysis of 6268 patients of the TraumaRegister DGU®

Background

Blood alcohol level (BAL) has previously been considered as a factor influencing the outcome of injured patients. Despite the well-known positive correlation between alcohol-influenced traffic participation and the risk of accidents, there is still no clear evidence of a positive correlation between blood alcohol levels and severity of injury. The aim of the study was to analyze data of the TraumaRegister DGU^® (TR-DGU), to find out whether the blood alcohol level has an influence on the type and severity of injuries as well as on the outcome of multiple-trauma patients.

Methods

Datasets from 11,842 trauma patients of the TR-DGU from the years 2015 and 2016 were analyzed retrospectively and 6268 patients with a full dataset and an AIS ≥ 3 could be used for evaluation. Two groups were formed for data analysis. A control group with a BAL = 0 ‰ (BAL negative) was compared to an alcohol group with a BAL of ≥0.3‰ to < 4.0‰ (BAL positive). Patients with a BAL >  0‰ and <  0.3‰ were excluded. They were compared with regard to various preclinical, clinical and physiological parameters. Additionally, a subgroup analysis with a focus on patients with a traumatic brain injury (TBI) was performed.

A total of 5271 cases were assigned to the control group and 832 cases to the BAL positive group. 70.3% (3704) of the patients in the control group were male. The collective of the control group was on average 5.7 years older than the patients in the BAL positive group (p < .001). The control group showed a mean ISS of 20.3 and the alcohol group of 18.9 (p = .007). In terms of the injury severity of head, the BAL positive group was significantly higher on average than the control group (p <  0.001), whereas the control group showed a higher AIS to thorax and extremities (p <  0.001). The mean Glasgow Coma Scale (GCS) was 10.8 in the BAL positive group and 12.0 in the control group (p <  0.001). Physiological parameters such as base excess (BE) and International Normalized Ratio (INR) showed reduced values ​​for the BAL positive group. However, neither the 24-h mortality nor the overall mortality showed a significant difference in either group (p = 0.19, p = 0.14). In a subgroup analysis, we found that patients with a relevant head injury (AIS: Abbreviated Injury Scale head ≥3) and positive BAL displayed a higher survival rate compared to patients in the control group with isolated TBI (p < 0.001).

Conclusions

This retrospective study analyzed the influence of the blood alcohol level in severely injured patients in a large national dataset. BAL positive patients showed worse results with regard to head injuries, the GCS and to some other physiological parameters. Finally, neither the 24-h mortality nor the overall mortality showed a significant difference in either group. Only in a subgroup analysis the mortality rate in BAL negative patients with TBI was significantly higher than the mortality rate of BAL positive patients with TBI. This mechanism is not yet fully understood and is discussed controversially in the literature.

Alcohol does not increase in-hospital mortality due to severe blunt trauma: an analysis of propensity score matching using the Japan Trauma Data Bank

Aim

Alcohol‐related problems, including trauma, are a great burden on global health. Alcohol metabolism in the Japanese population is genetically inferior to other races. This study aimed to evaluate the effects of alcohol use among a Japanese severe blunt trauma cohort.

Methods

This retrospective observational study analyzed the data of trauma patients registered in the Japan Trauma Data Bank between 2004 and 2019. The primary outcome of this study was in‐hospital mortality. The lengths of hospital and intensive care unit stay were the secondary outcomes. Propensity score matching was used to adjust the anatomical severity and patient background to reduce the potential alcohol use bias.

Results

We analyzed 46,361 patients categorized into nondrinking (n = 37,818) and drinking (n = 8,543) groups. After a 1:1 propensity score matching (n = 8,428, respectively), despite the Glasgow Coma Scale and Revised Trauma Score scores being significantly lower in the drinking group (14 vs. 13 and 7.84 vs. 7.55, P < 0.001, respectively) and intensive care unit length of stay being significantly longer in the drinking group (6 vs. 7 days, P = 0.002), in‐hospital mortality was significantly lower in the alcohol group (11.8% vs. 9.0%, P < 0.001) and there were no differences in the duration of hospital stay (19 vs. 19 days, P = 0.848).

Conclusion

Despite increasing physiological severity on admission, after adjusting for anatomical severity, alcohol consumption could be beneficial in severe blunt trauma patients as regards in‐hospital mortality.

Impact of blood alcohol concentration on hematologic and serum chemistry parameters in trauma patients: Analysis of data from a high-volume level 1 trauma center

Background

Alcohol (EtOH) intoxication is common among trauma patients. While providers are familiar with the clinical aspects of acute EtOH intoxication, few studies have investigated the effects that EtOH levels may have on common laboratory markers. The aim of this study was to identify hematologic and serum chemistry parameters that may be affected by the blood alcohol concentration (BAC), hypothesizing that BAC influences both comprehensive blood count (CBC) and comprehensive serum chemistry (CSC) components.

Methods

We performed an IRB-exempt institutional registry review of all trauma patients who had serum EtOH levels measured between January 2009 and June 2015. Data for each patient included: patient demographics, BAC determinations (g/dL), injury mechanism/severity information (ISS), hematologic parameters included in a CBC (hemoglobin, hematocrit, white blood cell [WBC] count, and platelet count), and CSC panel components (sodium, potassium, chloride, bicarbonate, blood urea nitrogen [BUN], creatinine, glucose, and hepatic function tests). Laboratory markers were contrasted across predefined categories of BAC: <0.10%, 10%-15%, 15%-20%, and >20%. Statistical comparisons were performed using SPSS 18 Software, employing analysis-of-covariance with adjustments performed for the patient demographics and injury characteristics. Statistical significance was set at α = 0.005.

Results

A total of 2167 patient records were analyzed. After adjusting for patient age, gender, and ISS, increasing BAC correlated with 4.8% increase in hemoglobin and 32.5% higher hematocrit (both P < 0.001), as well as a 27.8% decrease in WBC count. There were also statistically significant differences between low (<0.10%) and high (>0.20%) BAC groups across multiple CSC parameters, with largest impact on BUN (32.2% decrease); creatinine (31.5% decrease); and glucose (13.6% decrease) values. Elevated BAC (>0.20 g/dL) was also associated with 81.8% increase in total bilirubin, and hepatic transaminases were elevated among patients with BAC >0.10.

Conclusion

Due to the paucity of literature relating to the effects of BAC on serum hematologic and biochemical markers in acute trauma, this study provides a foundation for further exploration of these relationships and their clinical impact. More specifically, we found that BAC levels significantly influenced key laboratory markers, suggesting that acute EtOH intoxication may lead to hematologic and CSC changes that are potentially important in acute trauma management by frontline clinical staff.

Traumatic Brain Injury Related Hospitalizations: Factors Associated with In-hospital Mortality among Elderly Patients Hospitalized with a TBI

Background: This study aims to describe TBI-related hospitalizations for the whole population and identify factors associated with in-hospital mortality among elderly (≥65 years) patients hospitalized with TBI in Texas.Methods: Using Texas Hospital Discharge Data from 2012 to 2014, TBI-related hospitalizations were identified using International Classification of Diseases - Ninth Revision - Clinical Modification (ICD-9-CM) codes. Rates for age and gender were estimated using U.S. Census data. Univariate and multivariate analyses were used to identify factors associated with in-hospital mortality among those aged at least 65 years.Results: There were 51,419 TBI-related hospitalizations from 2012 to 2014 in Texas. Falls were the leading cause of TBI-related hospitalizations 6235 (36.64%), 6595 (38.40%), and 5412 (37.59%) for 2012, 2013, and 2014, respectively. Males had higher rates of hospitalizations while rates were highest for those above 80 years of age. Compared to Whites, Hispanics had 1.18 higher adjusted odds of in-hospital mortality [OR = 1.18: 95% CI (1.01-1.40)]. Similarly, adjusted odds of in-hospital mortality were higher among males [OR = 1.55: 95% CI (1.36-1.77)].Conclusion: This study provided evidence of demographic disparities in the burden and outcome of TBI in Texas, findings could serve as a foundation for targeted TBI prevention interventions.

Functional recovery after brain injury: Independent predictors of psychosocial outcome one year after TBI

INTRODUCTION

Traumatic Brain Injury (TBI) is the leading cause of death and disability in people aged under 40 in the UK. Many patients suffer residual deficits, which limits their functional recovery. The aim of this study was to determine independent predictors of functional outcome at 1-year post-TBI.

METHODS

Utilising a prospective observational cohort design, 1131 consecutive adult admissions with non-recurrent TBI were recruited from the ED (Emergency Department). Using routine consultant-led follow up clinics, data was collected between August 2011 and July 2015. The Rivermead Head Injury Follow Up Questionnaire (RHFUQ) was used to measure psychosocial function at 1 year.

RESULTS

A multiple linear regression model showed that previous psychiatric history (p < 0.001), lower Glasgow Coma Scale (p < 0.001), a severe CT scan (p = 0.002), aetiology of assault compared to sport (p = 0.011) and falls (p = 0.005), initial unemployment (p < 0.001) and no job at 8-10 weeks (p < 0.001) after TBI had a significant association with a worse RHFUQ score at 1 year. Follow up rate was >90 %.

CONCLUSIONS

This study adds valuable information on the prognostic indicators of TBI recovery and possible targets for intervention. Future development of a validated prognostic model to predict long term functional outcomes after TBI will help improve long-term treatment of the condition.

Pre-injury health status and excess mortality in persons with traumatic brain injury: A decade-long historical cohort study

An increasing number of patients are able to survive traumatic brain injuries (TBIs) with advanced resuscitation. However, the role of their pre-injury health status in mortality in the following years is not known. Here, we followed 77,088 consecutive patients (59% male) who survived the TBI event in Ontario, Canada for more than a decade, and examined the relationships between their pre-injury health status and mortality rates in excess to the expected mortality calculated using sex- and age-specific life tables. There were 5792 deaths over the studied period, 3163 (6.95%) deaths in male and 2629 (8.33%) in female patients. The average excess mortality rate over the follow-up period of 14 years was 1.81 (95% confidence interval = 1.76-1.86). Analyses of follow-up time windows showed different patterns for the average excess rate of mortality following TBI, with the greatest rates observed in year one after injury. Among identified pre-injury comorbidity factors, 33 were associated with excess mortality rates. These rates were comparable between sexes. Additional analyses in the validation dataset confirmed that these findings were unlikely a result of TBI misclassification or unmeasured confounding. Thus, detection and subsequent management of pre-injury health status should be an integral component of any strategy to reduce excess mortality in TBI patients. The complexity of pre-injury comorbidity calls for integration of multidisciplinary health services to meet TBI patients' needs and prevent adverse outcomes.

Factors with the strongest prognostic value associated with in-hospital mortality rate among patients operated for acute subdural and epidural hematoma

INTRODUCTION

Traumatic brain injury (TBI) still remains a serious health problem and is called a "silent epidemic". Each year in Europe 262 per 100,000 individuals suffer from TBI. The most common consequence of severe head injuries include acute subdural (SDH) and epidural hematomas (EDH), which usually require immediate surgically treatment. The aim of our study is to identify factors which have the strongest prognostic value in relation to in-hospital mortality rate among of patients undergoing surgery for EDH and SDH.

PATIENTS AND METHODS

Cohort included 128 patients with isolated craniocerebral injuries who underwent surgery for EDH (28 patients) and SDH (100 patients) in a single, tertiary care Department of Neurosurgery. The data were collected on admission of patients to the Emergency Department and retrospectively analyzed. The following factors were analyzed: demographic data, physiological parameters, laboratory variables, computed tomography scan characteristics and the time between trauma and surgery. Likewise, we have investigated the in-hospital mortality of patients at the time of discharge.

RESULTS

We found that the factors with the strongest prognostic values were: the initial GCS score, respiratory rate, glycaemia, blood saturation, systolic blood pressure, midline shift and type of hematoma. Additionally, we proved that a drop by one point in the GCS score almost doubles the risk of in-hospital death while the presence of coagulopathy increases the risk of in-hospital death almost six times.

CONCLUSION

Most of the factors with the strongest prognostic value are factors that the emergency team can treat prior to the hospital admission. Coagulopathy, however that has the strongest influence on in-hospital death rate can only be efficiently treated in a hospital setting.

The Initial Factors with Strong Predictive Value in Relation to Six-Month Outcome among Patients Operated due to Extra-Axial Hematomas

Introduction: Traumatic brain injuries (TBI) are a real social problem, with an upward trend worldwide. The most frequent consequence of a traumatic brain injury is extra-axial hemorrhage, i.e., an acute subdural (SDH) and epidural hematoma (EDH). Most of the factors affecting the prognosis have been analyzed on a wide group of traumatic brain injuries. Nonetheless, there are few studies analyzing factors influencing the prognosis regarding patients undergoing surgery due to acute subdural and epidural hematoma. The aim of this study was to identify the factors which have the strongest prognostic value in relation to the 6-month outcome of the patients undergoing surgery for SDH and EDH. Patients and methods: The study included a group of 128 patients with isolated craniocerebral injuries. Twenty eight patients were operated upon due to EDH, and a group of 100 patients were operated upon due to SDH. The following factors from the groups were analyzed: demographic data, physiological factors, laboratory factors, computed tomography scan characteristics, and time between the trauma and the surgery. All of these factors were correlated in a multivariate analysis with the six-month outcome in the Glasgow outcome scale. Results: The factors with the strongest prognostic value are GCS score, respiration rate, saturation, glycaemia and systolic blood pressure. Conclusion: Initial GCS score, respiratory rate, saturation, glycaemia and systolic blood pressure were the factors with the strongest prognostic value.

Alcohol is a predictor of mortality in motor vehicle collisions

INTRODUCTION

It is well recognized that driving while intoxicated increases the probability of a motor-vehicle collision (MVC). The effect of alcohol on the chance of surviving the MVC is less clear.

METHOD

Using data from the Fatality Analysis Reporting System (FARS) we conducted analyses for the outcome of mortality using alcohol and other variables as predictors. We also selected alcohol positive (AP) and alcohol negative (AN) persons from the same MVC and vehicle to control for confounding characteristics.

RESULTS

The odds ratio (OR) for mortality for alcohol positive drivers was 2.57, (p < 0.001 for all the following OR). Other harmful predictive factors were age OR 1.01 per year, vehicle age OR 1.05 per year, male sex OR 1.23, avoidance maneuver OR 1.09, speed related OR 2.89, rollover mechanism OR 2.75, and collision with a fixed object OR 6.70. Protective factors were proper restraint use - OR 0.19 and collision with another moving vehicle, OR 0.21. In the multivariate analysis the OR of mortality for AP vs AN was 1.46. Proper restraint use (OR 0.27) remained protective along with collision with another moving vehicle. When AP and AN persons from the same MVC and the same vehicle were compared, the adjusted OR's for mortality were 1.46 and 2.08, respectively.

CONCLUSIONS

Alcohol is an independent predictor of mortality in an MVC. Proper restraint use is the strongest protective factor. This finding allows a more complete understanding of the risks of driving while intoxicated, not only a higher probability of an MVC, but decreased survival once the MVC occurs. Practical Applications: Identification of alcohol as an independent predictor of mortality in an accident may improve risk assessment and influence drivers to avoid driving while intoxicated.

Alcohol and Drug Use Before and During the First Year After Traumatic Brain Injury

OBJECTIVES

To compare individuals with mild and moderate/severe traumatic brain injury (TBI) on alcohol and drug use and substance use disorders before and in the first year post-TBI; to explore sociodemographic and injury-related variables associated with substance use disorders.

PARTICIPANTS

A total of 225 adults hospitalized in a level I trauma center after TBI.

DESIGN

Observational cohort study with retrospective (pre-TBI) and prospective (4, 8, and 12 months post-TBI) assessments.

MAIN MEASURES

Mini International Neuropsychiatric Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

RESULTS

The percentage of participants using alcohol or drug declined shortly after the injury (4 months) but increased closer to preinjury levels by the end of the first year. Post-TBI alcohol use was higher after mild than moderate/severe TBI, but drug use was similar. About 11% of participants met criteria for a substance use disorder in the first year after TBI. Younger age, not being in a relationship, and suspected substance intoxication at the time of TBI were associated with the presence of a post-TBI substance use disorder.

CONCLUSION

Individuals with milder injuries return to alcohol use earlier than those with more severe injuries. Given that substance use may alter recovery, preventive recommendations and systematic follow-ups are warranted regardless of injury severity and access to rehabilitation.

Alcohol in Traumatic Brain Injury: Toxic or Therapeutic?

BACKGROUND

Alcohol (EtOH) poses a challenge in traumatic brain injuries (TBIs) given its metabolic and neurologic impact. Studies have had opposing results regarding mortality and complication rates in the intoxicated TBI patient. We hypothesized that trauma mechanism, brain injury severity, and blood alcohol concentration (BAC) would influence the impact of EtOH on mortality in TBI.

METHODS

We performed a single-institution retrospective review of consecutive adult trauma patients tested for EtOH and a diagnosis of TBI. The primary outcome was mortality, and secondary outcomes included infectious complications. The primary analysis included univariate and multivariate regression comparing mortality between intoxicated and sober patients, at different values of BAC, different brain injury severities, and among mechanisms of trauma.

RESULTS

Admission EtOH was assessed in 583 patients with TBI, with 256 testing positive for EtOH and 327 testing negative. Overall, EtOH was associated with lower mortality on univariate analysis (4.7% versus 8.9%, P = 0.05) but not on multivariate analysis (P = 0.21). There was no effect of EtOH on mortality when patients were stratified by brain injury severity or among penetrating trauma victims. However, EtOH was associated with lower overall infectious complications on univariate and multivariate regression. Finally, EtOH was predictive of mortality with an area under the receiver operator characteristic curve of 0.83.

CONCLUSIONS

We found that EtOH is not associated with mortality in the patient with TBI, suggesting no causative effect. However, EtOH showed some predictability of mortality based on a receiver operator characteristic analysis. Interestingly, EtOH was associated with lower infectious complications, suggesting an immunomodulatory effect of EtOH in TBI.

Very High Blood Alcohol Concentration and Fatal Hemorrhage in Acute Subdural Hematoma

INTRODUCTION

Alcohol intoxication is often present concurrently with traumatic brain injury (TBI). Recent studies have looked at the effect alcohol has on TBI and on coagulopathy. Typically, cases reviewed in the current literature report only on the effects of modest alcohol intoxication.

CASE DESCRIPTION

A 43-year-old male presented to the trauma center after a fall, with rapidly deteriorating mental status. Computed tomography of the head demonstrated a 1.9-cm acute subdural hematoma. Of note, classical coagulation studies were normal, but blood ethanol level was high, 436 mg/dL. Postoperatively, the patient suffered an intracerebral hemorrhage requiring emergent return to the operating room, where a large volume of unclotted blood and clinical coagulopathy was encountered.

DISCUSSION

We review the literature pertaining to coagulopathy in the context of TBI and ethanol intoxication. This case is a cautionary tale of a phenomenon of unmeasured coagulopathy in the face of severe alcohol intoxication manifested by intraoperative coagulopathy with new postoperative hemorrhage. Although routine preoperative testing indicated normal clotting function, a thromboelastogram demonstrated delayed clot formation. The protective effects of alcohol are well described; however, we believe that there is a population of patients with severe acute intoxication who have coagulopathy that may go undetected by routine preoperative screening.

CONCLUSIONS

Caution should be exercised when taking care of patients with very high levels of alcohol because physiologic derangements may be unpredictable. Additional research is needed for patients with very high levels of alcohol intoxication and the effect it may have on coagulation.

Fatal traumatic brain injuries during 13 years of successive alcohol tax increases in Finland - a nationwide population-based registry study

We sought to investigate how increases in alcohol taxation and changes in alcohol consumption were associated with the incidence rate of fatal traumatic brain injuries (TBI) in Finland during the years 2004–2016. Nationwide, mandatory cause of death database covering all deaths in Finland was searched for all deaths related to TBIs (ICD-10: S06.X) in persons ≥16 years of age during 2004–2016. Study period included 28,657,870 person-years and 325,514 deaths of which 12,110 were TBI-related. Occurrence rates were standardized to European 2013 standard population. Data for alcohol consumption were obtained from the National Institute for Health and Welfare and for alcohol taxation from Ministry of Finance, Finland. Standardized incidence rate of TBI-related death was 22.0 (95% CI 21.61–22.38) per 100,000 person-years. Overall alcohol consumption decreased on average by 1.2% annually. Concurrently, the overall incidence rate of fatal TBIs decreased by 4.1% annually (by 4.3% in men and 2.4% in women). There was an association between overall alcohol consumption and TBI-related mortality rate (p < 0.001). Tax-rate increases of all beverage types were associated with decreased incidence rate of TBI-related death in men (p < 0.001), in women (p < 0.036) and overall (p < 0.001). In this population-based study, we report that during 13 years of successive alcohol tax increases, overall alcohol consumption has decreased in parallel with a reduction in the incidence rate of fatal TBIs in Finland.

Circulating Extracellular Vesicles and Their miR "Barcode" Differentiate Alcohol Drinkers With Liver Injury and Those Without Liver Injury in Severe Trauma Patients

Short Summary: Extracellular vesicles (EVs), released during tissue/cell injury, contain a “barcode” indicating specific microRNAs (miRs) that can uncover their origin. We examined whether systemic EVs possessing hepatic miR-signatures would indicate ongoing liver injury and clinical complications in trauma patients (TP). We grouped the patients of alcoholic drinkers into “alcohol-drinkers with liver injury (LI)” (EtOH with LI) or “alcohol-drinkers without LI” (EtOH w/o LI) and we compared these groups to “non-drinkers” (no EtOH). When we examined patient blood from the EtOH with LI group we found the total number of EVs to be increased, along with an increase in miR-122 and let7f—two EV-associated miRNAs—and several inflammation-associating cytokines, such as interleukin (IL)-6 and IL-33. In contrast, all of the aforementioned readouts were found to be decreased in the EtOH w/o LI group. These novel data demonstrate that hepatocyte damage in alcohol-intoxicated trauma patients presenting with liver injury can be reflected by an increase in circulating serum EVs, their specific miR-“barcode” and the concomitant increase of systemic inflammatory markers IL-6 and IL-33. Anti-inflammatory effect of alcohol-drinking in EtOH w/o LI can be presented by a reduced number of hepato-derived EVs, no upregulation of IL-6 and IL-33, and a miR “barcode” different from patients presenting with liver injury.

Background: Alcohol abuse is associated with (neuro)protective effects related to (head) injuries, and with negative effects regarding infection rates and survival in severely injured trauma patients (TP). Extracellular vesicles (EVs), which are released during tissue and/or cell injury, can contain a “barcode” including specific microRNAs (miRs) that uncover their origin. We examined whether EVs with a hepatic miR signature can be systemically measured, and whether they can indicate ongoing liver injury in alcohol-intoxicated TP and foretell clinical complications.

Patients/Methods: We enrolled 35 TP and measured blood EVs, IL-6, TNF-alpha, IL-1beta, IL-10 and IL-33, alcohol (ethanol, EtOH) concentration (BAC), GLDH, GGT, AST, ALT, leukocytes, platelets, and bilirubin. Within circulating EVs we measured the expression levels of miR-122, let7f, miR21, miR29a, miR-155, and miR-146a. Patients of alcohol-drinkers were grouped into “alcohol drinkers with liver injury (LI)” (EtOH with LI) or “alcohol drinkers without LI” (EtOH w/o LI) and compared to “non-drinkers” (no EtOH). We assessed systemic injury characteristics and the outcome of hospitalization with regard to sepsis, septic shock, pneumonia, or mortality.

Results: EtOH with LI patients had significantly increased rates of pneumonia vs. the EtOH w/o LI group. EVs, IL-6, and IL-33 levels were significantly increased in EtOH with LI vs. EtOH w/o LI group (p < 0.05). EV number correlated positively with ALT and IL-6 (p < 0.0001). Two miRs, miR-122 and let7f, were increased only in the blood EVs from the EtOH with LI group (p < 0.05). Five miRs, miR-122, let7f, miR-21, miR-29a, and miR-146a, were reduced in the blood EVs from the EtOH w/o LI group, vs. no EtOH (p < 0.05). Notably miR-122 correlated significantly with increased bilirubin levels in the EtOH with LI group (p < 0.05).

Conclusions: Liver injury in alcohol-intoxicated TP is reflected by increased EV numbers, their specific miR barcode, and the correlated increase of systemic inflammatory markers IL-6 and IL-33. Interestingly, severely injured TP without liver injury were found to have a reduced number of liver-derived EVs, no observed inflammatory infiltration and reduced specific miR “barcode.”

The Neuroprotective Effect of Ethanol Intoxication in Traumatic Brain Injury Is Associated with the Suppression of ErbB Signaling in Parvalbumin-Positive Interneurons

Ethanol intoxication (EI) is a frequent comorbidity of traumatic brain injury (TBI), but the impact of EI on TBI pathogenic cascades and prognosis is unclear. Although clinical evidence suggests that EI may have neuroprotective effects, experimental support is, to date, inconclusive. We aimed at elucidating the impact of EI on TBI-associated neurological deficits, signaling pathways, and pathogenic cascades in order to identify new modifiers of TBI pathophysiology. We have shown that ethanol administration (5 g/kg) before trauma enhances behavioral recovery in a weight-drop TBI model. Neuronal survival in the injured somatosensory cortex was also enhanced by EI. We have used phospho-receptor tyrosine kinase (RTK) arrays to screen the impact of ethanol on TBI-induced activation of RTK in somatosensory cortex, identifying ErbB2/ErbB3 among the RTKs activated by TBI and suppressed by ethanol. Phosphorylation of ErbB2/3/4 RTKs were upregulated in vGlut2⁺ excitatory synapses in the injured cortex, including excitatory synapses located on parvalbumin (PV)-positive interneurons. Administration of selective ErbB inhibitors was able to recapitulate, to a significant extent, the neuroprotective effects of ethanol both in sensorimotor performance and structural integrity. Further, suppression of PV interneurons in somatosensory cortex before TBI, by engineered receptors with orthogonal pharmacology, could mimic the beneficial effects of ErbB inhibitors. Thus, we have shown that EI interferes with TBI-induced pathogenic cascades at multiple levels, with one prominent pathway, involving ErbB-dependent modulation of PV interneurons.

Effects of acute ethanol intoxication in an ovine peritonitis model

BACKGROUND

Acute ethanol intoxication has been shown to have contrasting effects on outcomes in sepsis. The aim of this study was to explore the effects of acute ethanol intoxication on hemodynamics, renal function, brain perfusion and lactate/pyruvate in an ovine sepsis model.

METHODS

Anesthetized, mechanically ventilated female sheep were randomized to an ethanol group (n = 7), which received 1 g/kg ethanol diluted in intravenous (i.v.) saline infusion or a control group (n = 7), which received the same volume of i.v. saline. Both groups received the treatment for a period of 2 h prior to induction of sepsis by intraperitoneal injection of feces. Other treatment included fluid resuscitation but no vasopressors or antibiotics. Global hemodynamics, renal blood flow, brain cortex laser Doppler flowmetry and microdialysis analyses were recorded hourly.

RESULTS

In the ethanol group, blood ethanol concentrations were 137 ± 29 mg/dL at the time of feces injection and decreased to become undetectable by 12 h. Arterial hypotension occurred earlier in the ethanol than in the control group (8 [7-12] vs. 14 [11-20] hours, p = 0.03). Lactate levels increased to > 2 mmol/L earlier in the ethanol group. Renal dysfunction (9 [6-13] vs. 13 [12-15] hours, p = 0.05) and oliguria (urine output < 0.5 mL/kg/h; 10 [7-12] vs. 13 [12, 13] hours, p = 0.01) developed earlier in the ethanol than in the control group. Brain blood flow and lactate/pyruvate were unaffected. There was no significant difference in survival time.

CONCLUSIONS

Acute ethanol intoxication in this model of peritonitis resulted in earlier development of shock and renal dysfunction but did not alter brain perfusion and metabolism or short-term survival.

Neuroprotective effect of acute ethanol intoxication in TBI is associated to the hierarchical modulation of early transcriptional responses

Ethanol intoxication is a risk factor for traumatic brain injury (TBI) but clinical evidence suggests that it may actually improve the prognosis of intoxicated TBI patients. We have employed a closed, weight-drop TBI model of different severity (2cm or 3cm falling height), preceded (-30min) or followed (+20min) by ethanol administration (5g/Kg). This protocol allows us to study the interaction of binge ethanol intoxication in TBI, monitoring behavioral changes, histological responses and the transcriptional regulation of a series of activity-regulated genes (immediate early genes, IEGs). We demonstrate that ethanol pretreatment before moderate TBI (2cm) significantly reduces neurological impairment and accelerates recovery. In addition, better preservation of neuronal numbers and cFos+cells was observed 7days after TBI. At transcriptional level, ethanol reduced the upregulation of a subset of IEGs encoding for transcription factors such as Atf3, c-Fos, FosB, Egr1, Egr3 and Npas4 but did not affect the upregulation of others (e.g. Gadd45b and Gadd45c). While a subset of IEGs encoding for effector proteins (such as Bdnf, InhbA and Dusp5) were downregulated by ethanol, others (such as Il-6) were unaffected. Notably, the majority of genes were sensitive to ethanol only when administered before TBI and not afterwards (the exceptions being c-Fos, Egr1 and Dusp5). Furthermore, while severe TBI (3cm) induced a qualitatively similar (but quantitatively larger) transcriptional response to moderate TBI, it was no longer sensitive to ethanol pretreatment. Thus, we have shown that a subset of the TBI-induced transcriptional responses were sensitive to ethanol intoxication at the instance of trauma (ultimately resulting in beneficial outcomes) and that the effect of ethanol was restricted to a certain time window (pre TBI treatment) and to TBI severity (moderate). This information could be critical for the translational value of ethanol in TBI and for the design of clinical studies aimed at disentangling the role of ethanol intoxication in TBI.

An erroneous opinion on a cause of death in a forensic autopsy: a case report

Background

The quality of autopsies is always questioned in courts, especially in developing countries. Wrong decisions or misjudgments are undesirable in medicine, but they are very dangerous in forensic medicine. If a wrong opinion is given, either a culprit can be acquitted or an innocent person can be sentenced. Therefore, an expert opinion is always required before the announcement of a judgment.

Objective

To highlight the problem of accuracy in determining the cause of death in forensic autopsy.

Case history

A 19- year old young adult male (Mr E), who had a history of alcohol abuse, was brought to a hospital casualty department by police, on an allegation of theft. He was unconscious and died within two hours of arrival. A post-mortem report was requested by a private attorney for an expert opinion. A post-mortem examination was conducted and multiple superficial injuries were recorded on his body. Head injury was given as a cause of death. The author seeks to critically analyze the post-mortem findings in relation to the cause and manner of death.

Conclusion

An erroneous opinion was reached regarding cause and manner of death in this autopsy report.

Acute ethanol administration results in a protective cytokine and neuroinflammatory profile in traumatic brain injury

Ethanol intoxication is a common comorbidity in traumatic brain injury. To date, the effect of ethanol on TBI pathogenic cascades and resulting outcomes remains debated. A closed blunt weight-drop murine TBI model has been implemented to investigate behavioral (by sensorimotor and neurological tests), and neuro-immunological (by tissue cytokine arrays and immuno-histology) effects of ethanol intoxication on TBI. The effect of the occurrence of traumatic intracerebral hemorrhage was also studied. The results indicate that ethanol pretreatment results in a faster and better recovery after TBI with reduced infiltration of leukocytes and reduced microglia activation. These outcomes correspond to reduced parenchymal levels of GM-CSF, IL-6 and IL-3 and to the transient upregulation of IL-13 and VEGF, indicating an early shift in the cytokine profile towards reduced inflammation. A significant difference in the cytokine profile was still observed 24h post injury in the ethanol pretreated mice, as shown by the delayed peak in IL-6 and by the suppression of GM-CSF, IFN-γ, and IL-3. Seven days post-injury, ethanol-pretreated mice displayed a significant decrease both in CD45+ cells infiltration and in microglial activation. On the other hand, in the case of traumatic intracerebral hemorrhage, the cytokine profile was dominated by KC, CCL5, M-CSF and several interleukins and ethanol pretreatment did not produce any modification. We can thus conclude that ethanol intoxication suppresses the acute neuro-inflammatory response to TBI, an effect which is correlated with a faster and complete neurological recovery, whereas, the presence of traumatic intracerebral hemorrhage overrides the effects of ethanol.

Acute Alcohol Exposure and Risk of Mortality of Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis

After traumatic brain injury (TBI), patients usually live with significant disability and socioeconomic burdens. Acute exposure to alcohol is considered a major risk factor for TBI. Numerous studies have examined whether alcohol exposure is related to the risk of mortality in patients with TBI, yet the results remain inconsistent. We performed a meta-analysis to assess whether acute alcohol exposure affects the mortality rate of TBI patients. We searched PubMed, EMBASE, and the Cochrane Library up to November 2015 for relevant studies. We screened studies based on their inclusion criteria and selected the studies that reported mortality rate, which included 18 observational studies. We used R to analyze the included data. An initial result showed that the presence of a positive blood alcohol concentration (BAC) had no significant relation with mortality rate (OR = 0.92, 95% CI = 0.83 to 1.01), but there was notable heterogeneity along with variable results according to sensitivity analysis. For the BAC-positive population, low BAC (1 to 100 mg/dl) carried a higher risk of mortality than moderate BAC (100 to 230 mg/dl) (OR = 1.40, 95% CI = 1.09 to 1.81), moderate and high BAC as a single category (>100 mg/dl) (OR = 1.57, 95% CI = 1.28 to 1.94), or high BAC (>230 mg/dl) (OR = 1.76, 95% CI = 1.34 to 2.30). However, moderate BAC did not increase the mortality risk when compared with high BAC (OR = 1.20, 95% CI = 0.89 to 1.63). Whether positive BAC at the time of admission after TBI reduces mortality rate compared with the rate under negative BAC remains unknown. In addition, low BAC (1 to 100 mg/dl) poses a risk of mortality compared with higher BAC. Further studies assessing the effect of alcohol between the BAC-positive group and the BAC-negative group are still needed.

Hemotransfusion and mechanical ventilation time are associated with intra-hospital mortality in patients with traumatic brain injury admitted to intensive care unit

OBJECTIVE

To identify the factors associated with the intra-hospital mortality in patients with traumatic brain injury (TBI) admitted to intensive care unit (ICU).

METHODS

The sample included patients with TBI admitted to the ICU consecutively in a period of one year. It was defined as variables the epidemiological characteristics, factors associated with trauma and variables arising from clinical management in the ICU.

RESULTS

The sample included 87 TBI patients with a mean age of 28.93 ± 12.72 years, predominantly male (88.5%). The intra-hospital mortality rate was of 33.33%. The initial univariate analysis showed a significant correlation of intra-hospital death and the following variables: the reported use of alcohol (p = 0.016), hemotransfusion during hospitalization (p = 0.036), and mechanical ventilation time (p = 0.002).

CONCLUSION

After multivariate analysis, the factors associated with intra-hospital mortality in TBI patients admitted to the intensive care unit were the administration of hemocomponents and mechanical ventilation time.

Binge ethanol in adulthood exacerbates negative outcomes following juvenile traumatic brain injury

Traumatic brain injuries (TBI) are a major public health problem with enormous costs in terms of health care dollars, lost productivity, and reduced quality of life. Alcohol is bidirectionally linked to TBI as many TBI patients are intoxicated at the time of their injury and we recently reported that, in accordance with human epidemiological data, animals injured during juvenile development self-administered significantly more alcohol as adults than did sham injured mice. There are also clinical data that drinking after TBI significantly reduces the efficacy of rehabilitation and leads to poorer long-term outcomes. In order to determine whether juvenile traumatic brain injury also increased the vulnerability of the brain to the toxic effects of high dose alcohol, mice were injured at 21days of age and then seven weeks later treated daily with binge-like levels of alcohol 5g/kg (by oral gavage) for ten days. Binge-like alcohol produced a greater degree of neuronal damage and neuroinflammation in mice that sustained a TBI. Further, mice that sustained a juvenile TBI exhibited mild learning and memory impairments in adulthood following binge alcohol and express a significant increase in hippocampal ectopic localization of newborn neurons. Taken together, these data provide strong evidence that a mild brain injury occurring early in life renders the brain highly vulnerable to the consequences of binge-like alcohol consumption.

Examining the Relationship Between Traumatic Brain Injury and Substance Use Outcomes in the Canadian Population

BACKGROUND

The literature has opposing views regarding the magnitude of the association between substance use and TBI. Most studies have examined clinical samples which are not representative of the entire head injured population. Clinical samples provide very limited insight into TBI patients whom do not seek care.

OBJECTIVES

This paper examines the associations between TBI and substance use/misuse. Its primary aim is to test whether or not individuals with a past-year TBI have higher rates of substance use/misuse than Canadians without a TBI or back and/or spine injury controls drawing on self-report population level data.

METHODS

Using the 2009-2010 Canadian Community Health Survey, a nationally representative cross-sectional survey of Canadians 12 years and older, this paper assessed substance use (i.e., illicit drug use; drinking and binge drinking; current smoking) among those with a TBI, as compared to two control groups: (1) individuals with a back or spinal injury (BSI); and (2) healthy noninjured controls. Multivariate regressions (logistic and multinomial), both unadjusted and adjusting for a range of injury and sociodemographic covariates, were used in hypothesis testing.

RESULTS

Those with a past-year TBI demonstrated significantly elevated rates of illicit drug use relative to non-injured Canadians. Relative to the BSI group those with a TBI were less likely to drink alcohol, did not differ in binge drinking, cigarette smoking and illicit drug use.

CONCLUSION

Health care professionals working with the TBI population should integrate screening, brief intervention, and referral programming as a means to reduce future harm related to substance misuse.

Impact of day-of-injury alcohol consumption on outcomes after traumatic brain injury: A meta-analysis

Although a known risk factor for traumatic brain injury (TBI), alcohol has been found to both promote and protect against secondary brain damage. However, it is presently unclear whether the cognitive, psychological and medical/functional outcomes of adults who have consumed alcohol prior to sustaining a TBI differ from those who have not. This meta-analysis examined the outcomes of groups that differed in terms of their day-of-injury (DOI) blood alcohol levels (BALs) by comparing positive with zero BAL (BAL⁺/BAL^-) and high with low BAL (BAL^high/BAL^low) samples. The PubMed, PsycINFO, EMBASE, and Scopus databases were searched from inception until the end of March 2015. Hedge's g effects (continuous data) and odds ratios (categorical data) were calculated for 27 studies that compared either the outcomes of BAL⁺ and BAL^- groups or BAL^high and BAL^low groups. BAL⁺ was associated with significantly poorer cognitive outcomes (overall and on general tests) and higher levels of disability, and BAL^high was associated with shorter stays in intensive care. More generally, however, most effect sizes were small to low-moderate in size, non-significant and inconsistent in their direction. Although DOI alcohol consumption increases the risk of sustaining a TBI, it is not consistently associated with better or worse outcomes, other than subtle cognitive deficits; the source of which remains to be determined.

Pharmacologic Neuroprotection for Functional Outcomes After Traumatic Brain Injury: A Systematic Review of the Clinical Literature

INTRODUCTION

Traumatic brain injury (TBI) is a major cause of death and disability worldwide. The deleterious effects of secondary brain injury may be attenuated by early pharmacological therapy in the emergency room and intensive care unit (ICU). Current medical management of acute TBI is primarily supportive, aimed at reducing intracranial pressure (ICP) and optimizing cerebral perfusion. There are no pharmacological therapies to date that have been unequivocally demonstrated to improve neurological outcomes after TBI.

OBJECTIVES

The purpose of this systematic review was to evaluate the recent clinical studies from January 2013 through November 2015 that investigated neuroprotective functional outcomes of pharmacological agents after TBI.

METHODS

The following databases were searched for relevant studies: MEDLINE (OvidSP January Week 1, 2013-November Week 2 2015), Embase (OvidSP 2013 January 1-2015 November 24), and the unindexed material in PubMed (National Library of Medicine/National Institutes of Health [NLM/NIH]). This systematic review included only full-length clinical studies and case series that included at least five patients and were published in the English language. Only studies that examined functional clinical outcomes were included.

RESULTS

Twenty-five of 527 studies met our inclusion criteria, which investigated 15 independent pharmacological therapies. Eight of these therapies demonstrated possible neuroprotective properties and improved functional outcomes, of which five were investigated with randomized clinical trials: statins, N-acetyl cysteine (NAC), Enzogenol, Cerebrolysin, and nitric oxide synthase inhibitor (VAS203). Three pharmacological agents did not demonstrate neuroprotective effects, and four agents had mixed results.

CONCLUSIONS

While there is currently no single pharmacological therapy that will unequivocally improve clinical outcomes after TBI, several agents have demonstrated promising clinical benefits for specific TBI patients and should be investigated further.

Acute Alcohol Use and Injury Patterns in Young Adult Prehospital Patients

The objective was to determine if acute alcohol consumption is associated with differences in injury pattern among young adult patients with traumatic injuries presenting to emergency medical services (EMS). A cross-sectional, retrospective review of prehospital patient care reports (PCRs) was conducted evaluating injured patients who presented to a collegiate EMS agency from January 1, 2011 to December 31, 2012. Included patients were age 18-24 y and sustained an injury within the previous 24 h. PCRs were reviewed independently by two abstractors to determine if the patient was documented to have acutely consumed alcohol proximate to his/her injury. Primary and secondary sites of regional body injury were recorded. Injury severity was recorded using the Revised Trauma Score (RTS). The association between primary injury site and acute alcohol use was assessed using a chi-square test. Multiple logistic regression was used to control for sex in predicting injury type. Of 440 injured patients, 135 (30.6%) had documented alcohol use prior to injury. Acute alcohol consumption altered the overall pattern of regional injury (p < 0.001). Alcohol users were more likely to present with injury secondary to assault, fall/trip, and unknown mechanism of injury (p < 0.001, all comparisons). RTS scores were statistically lower in the alcohol group (p < 0.001), although the clinical significance of this is unclear. Controlling for sex, acute alcohol consumption predicted increased risk of head/neck injury 5.59-fold (p < 0.001). Acute alcohol use in collegiate EMS patients appears to alter injury patterns in young adults and increases risk of head/neck injury. EMS providers in similar agencies should consider these trends when assessing and treating injured college-aged patients.

Effects of positive blood alcohol concentration on outcome and systemic interleukin-6 in major trauma patients

BACKGROUND

The influence of alcohol on the outcome after major trauma remains controversial. In several recent studies, alcohol has been associated with neuroprotective effects in head injuries, while others reported negative or no effects on survival and/or the in-hospital stay in major trauma patients (TP). The purpose of this study was to examine the relationship of alcohol with injury characteristics and outcome as well as to analyze possible anti-inflammatory properties in major TP.

PATIENTS/METHODS

184 severely injured TP with an Injury Severity Score (ISS) ≥16 were successively enrolled. All patients had measured blood alcohol concentration (BAC). Patients were grouped according to their positive BAC (>0.5‰, BAC) vs. <0.5‰ alcohol (no BAC) upon arrival at the emergency department (ED). Injury characteristics, physiologic parameters and outcome with respect to organ or multiple organ failure (MOF), SIRS, sepsis, pneumonia, ARDS or mortality were assessed. Systemic levels of interleukin (IL)-6 at ED were determined.

RESULTS

Forty-nine TP had positive BAC without chronic alcohol abuse history and 135 patients had BAC levels below 0.5‰. Overall injury severity and age were comparable in both groups. No BAC TP received significantly higher numbers of packed red blood cells and fresh frozen plasma (transfused within the initial 24h or in total) compared to BAC TP. Organ failure, MOF, SIRS, sepsis, pneumonia, ARDS and the in-hospital mortality were not different between both groups. Trauma patients with positive BAC had significantly decreased leukocyte numbers and systemic IL-6 levels compared to no BAC group. There was a significant positive correlation between leukocyte counts and IL-6 as well as BAC and leukocytes. BAC levels did not correlate with IL-6.

CONCLUSIONS

Positive BAC is associated with reduced leukocyte numbers and lowered systemic IL-6 levels at admittance indicating immune-suppressive effects of alcohol in major trauma patients.

Differential Relevance of NF-κB and JNK in the Pathophysiology of Hemorrhage/Resususcitation-Induced Liver Injury after Chronic Ethanol Feeding

BACKGROUND

Chronic ethanol (EtOH) abuse worsens pathophysiological derangements after hemorrhagic shock and resuscitation (H/R) that induce hepatic injury and strong inflammatory changes via JNK and NF-κB activation. Inhibiting JNK with a cell-penetrating, protease-resistant peptide D-JNKI-1 after H/R in mice with healthy livers ameliorated these effects. Here, we studied if JNK inhibition by D-JNKI-1 in chronically EtOH-fed mice after hemorrhagic shock prior to the onset of resuscitation also confers protection.

METHODS

Male mice were fed a Lieber-DeCarli diet containing EtOH or an isocaloric control (ctrl) diet for 4 weeks. Animals were hemorrhaged for 90 min (32 ± 2 mm Hg) and randomly received either D-JNKI-1 (11 mg/kg, intraperitoneally, i. p.) or sterile saline as vehicle (veh) immediately before the onset of resuscitation. Sham animals underwent surgical procedures without H/R and were either D-JNKI-1 or veh treated. Two hours after resuscitation, blood samples and liver tissue were harvested.

RESULTS

H/R induced hepatic injury with increased systemic interleukin (IL)-6 levels, and enhanced local gene expression of NF-κB-controlled genes such as intercellular adhesion molecule (ICAM)-1 and matrix metallopeptidase (MMP)9. c-Jun and NF-κB phosphorylation were increased after H/R. These effects were further increased in EtOH-fed mice after H/R. D-JNKI-1 application inhibited the proinflammatory changes and reduced significantly hepatic injury after H/R in ctrl-fed mice. Moreover, D-JNKI-1 reduces in ctrl-fed mice the H/R-induced c-Jun and NF-κB phosphorylation. However, in chronically EtOH-fed mice, JNK inhibition did not prevent the H/R-induced hepatic damage and proinflammatory changes nor c-Jun and NF-κB phosphorylation after H/R.

CONCLUSIONS

These results indicate, that JNK inhibition is protective only in not pre-harmed liver after H/R. In contrast, the pronounced H/R-induced liver damage in mice being chronically fed with ethanol cannot be prevented by JNK inhibition after H/R and seems to be under the control of NF-κB.